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Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
Pharmaceutical Care of People with Chronic Pain
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Pharmaceutical Care of People with Chronic Pain

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Pharmaceutical Care of People with Chronic Pain …

Pharmaceutical Care of People with Chronic Pain
Dr Deboorah Paton

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  • Complicated by central processing that allows pain to be experienced as a cognitive function.. How we interpret pain is important and can affect patients life 0- as shown in next slide where the interplay of afferent and efferent fibres is demonstrated.
  • Expand on neural plasticity here – changes in chronic pain vs acute pain is important Why pain is different than hypertension eg
  • Medication acts on different areas of this pathway Ask the audience what medication is effective at each Here we can add in the five points to pain NSAIDs at periphery mostly Paracetamol – or acetaminophen centrally Opioids on ascending pathways interfere with sP A beta fibres affecting gating of pain in S G – T cells Descending pathways also affect T cells in SG
  • Neuropathic pain caused by damage to or a dysfunction of the nervous system e.g. post herpetic neuralgia, diabetic neuropathy, pain following trauma or compression is generally un-diagnosed and poorly managed Nociceptive pain is caused by noxious stimuli of pain receptors with info transferred centrally e.g inflammation or headache, it is managed by analgesics, NSAIDs or opioids
  • Refer Dr in Leprosy and pain experienced OR rather NOT experienced Hypnotherapy Californian paramedics etc – farmers with limbs off can switch off pain
  • How many patients will a pharmacist see What drugs are used in your experience How many are sub-therapeutic?
  • We should remind folk of the 10% rule 30mg codeine = 3mg morphine
  • TCA 10mg start point – emphasise mistake of starting too high in dose – side effects Nortriptyline perhaps less sedating? Explain HOW TCAs work on sodium channels – same way as anticonvulsants SSRI useful in Fibromyalgia
  • Specific indication in trigeminal neuralgia for carbamazepine
  • Might be helpful to add picture of areas likely to be affected-to allow differentiation between OA and RA-if patient just reports having arthritis Yes – affects “big “ joints – knee, hip etc Note degree of damage on flat film is often unrelated to pain experienced
  • Point out obvious damage and change in joint Osteophyte vs osteoblasts
  • Erythrocyte sedimentation rate Rheumatoid factor C reactive protein (usually diagnosis on signs and symptoms Smaller joints 0- hands as here disease-modifying anti-rheumatic drugs - discuss referral to specialist
  • You might want to suggest how pain diaries might be used-to identify what exacerbates pain, how it varies through the day or to show how changes in medication work-I used it to show how effective regular paracetamol is and taking medication before activities yes I will add this in here – OA for example can ease of as movement then get worse on over exercise
  • Transcript

    • 1. Pharmaceutical Care of people with Chronic Pain Deborah Paton Lead Pharmacist Pain Management NHS Fife NHS Fife
    • 2. Objectives
      • To provide an overview of the aetiology and therapeutic management of chronic pain
      • Identify the key pharmaceutical care issues of people with chronic pain
      • Explore ways of positively impacting on the care of this patient group
    • 3. What causes pain?
      • Trauma/ injury initiates immediate nerve impulses to brain
      • Injury to cells result in chemical release
          • H +
          • K +
          • Substance P
          • Bradykinin
          • 5HT
          • Phospholipids  Prostaglandins
      • Blood vessels leak resulting in inflammation
      • Stimulate C-fibres (slow response)
    • 4. Pain Pathway
    • 5. Nerve Fibres
      •  ( A delta)
          • Myelinated
          • Fast conductors
          • Gentle pressure and pain
      •  (A beta)
          • Thinner – but still myelinated
          • Fast conductors
          • Heavy pressure &temp
      • C - very thin
          • Slow conductors
          • PAIN, Pressure, temp & chemicals
    • 6. Categorisation of pain
    • 7. Different types of pain Stabbing Splitting Sharp Aching Hot-burning Gnawing, heavy Shooting Cramping, tender Neuropathic descriptors Nociceptive descriptors
    • 8. Acute Pain
      • Essential biological response to injury
      • Last a short time <1month
      • Associated with anxiety and hyperactivity of sympathetic nervous system
    • 9. Chronic Pain
      • Pain persisting/recurring for >3months after acute injury
      • Associated with changes in structure and operation of central
      • nervous system
      • Cognitive control-behavioural models important
      • Pain assessment is essential component of management
    • 10. Chronic Pain in Scotland (2004 Foster Project)
      • Prevalence of 18 % of the population
      • How many patients do you see as a pharmacist with chronic pain?
      • What medications have been “tried out” with these patients
      • Few Primary Care Organisation (PCOs) provide guidance for medication & management of non-malignant chronic pain.
      • Only 33% PCOs operate a formal/structured service for chronic pain management in primary care
    • 11. Pain Assessment
      • Severity
      • Location
      • Duration
      • Intensity
      • Periods of remission and degree of fluctuation
      • Exacerbating & relieving factors
      • Response to treatment
      • Psychological factors
      • Sociological factors
    • 12. Pain Assessment
      • > Individualised- what does it mean to the patient?
      • > Subjective
      • > Quality of Life- pain diaries
      • > Identify neuropathic elements
      • > Identify safety issues
    • 13. Pain Management-Principles of Treatment
      • - By the Mouth
      • - By the Clock
      • - By the Ladder
      • - Individualised treatment
      • - Patient involvement & goal setting > they manage pain not the reverse
    • 14. WHO 3 step ladder
    • 15. Analgesic medication key points
      • * Paracetamol round the clock & explore and dispel fears of safety or ineffectiveness
      • * Codeine-15% unable to metabolise - add in doses of
      • 30 mg codeine or 30mg dihydrocodeine if necessary – using lower doses not supported by evidence.
      • * Note need for laxative at therapeutic doses of opioids
      • * Separate agents are recommended > allows flexibility and self management
    • 16. NSAIDs
      • NSAIDs always consider is there an active indication e.g. is inflammation present in OA?
      • Full inflammatory effect can take 2-4 weeks & 60% will benefit from first choice-has there been an appropriate trial?
      • Lowest effective dose in pulse or prn basis where possible
      • Is there a risk of GI bleed? If yes review continued need and consider gastroprotectant
    • 17. NSAIDs Risks
      • Over 20% of drug related hospital admissions are due to NSAIDs
      • Absolute risk: over 65 years, previous GI bleed, previous peptic ulcer-aide memoir
      • Risk with increasing dose, type and duration of therapy, age, concurrent medication and co-morbidities
      • - 50-60% of people who will have GI bleed are asymptomatic before presentation
    • 18. NSAIDs vs COX IIs
      • > NSAIDs & Cox IIs equally effective
      • > Cox-II better tolerated but not safer (CV risk)
      • > NSAID plus gastro-protectant equally effective at reducing ulcers/bleeds
      • > Similar non GI risks – risk of PPI increase in infection rate?
      • > NSAID plus aspirin-if pain control required consider non-NSAID, in presence of inflammation or if required for long term use add PPI-
      • > Avoid Cox-IIs plus aspirin negation of GI benefit - this is under review.
    • 19. Neuropathic pain Adjuvant Analgesics Antidepressants
      • Tricyclic antidepressants
          • Amitriptyline/ Nortriptyline/ Clomipramine
          • Unlicensed use
          • Beneficial in neuropathic ‘burning’ pain
      • SNRI
          • Duloxetine/ Venlafaxine
          • Unlicensed use
          • Improves mood and increases Serotonin& Noradrenaline at synapses
      • SSRI- no real evidence
          • Fluoxetine/ paroxetine
          • Unlicensed use
          • Improves mood and increases Serotonin at synapses
    • 20. Adjuvant Analgesics Anticonvulsants
      • Carbamazepine & Valproate useful in ‘shooting pain’ indications
      • (e.g. trigeminal neuralgia)
      • Gabapentin / Pregabalin
      • - Acts centrally, GABA analogue
        • - Slow titration, particularly in elderly
    • 21. Adjuvant Analgesics Corticosteroids
      • Prednisolone & dexamethasone
      • Used to control inflammation where NSAIDs insufficient e.g. Rheumatoid conditions
      • Intra-articular route may give relief for a few months
    • 22. Topical products
      • -Topical NSAIDs v Rubefacients was previously contentious
      • - Some evidence to suggest Topical NSAIDs useful in small joint inflammation
      • - Stimulate A  fibres increasing inhibitory response?
      • - Counter irritant
      • - Capsaicin, derived from chilli peppers useful in diabetic neuropathy and OA
    • 23. Osteoarthritis
      • Active disease (inflammation), not just wear & tear
      • Degenerative disorder of cartilage and bone
      • Age, obesity & genetics related
      • Affects 50% of population >60yrs
      • - Diagnosed through x-ray or arthroscopy
    • 24. Osteoarthritis
      • - Aim of treatment is pain relief & mobilisation
      • - Regular simple analgesics particularly paracetamol
      • - NSAIDs-caution in long-term use
      • - Intra-articular steroids
      • - Weight reduction
      • - Joint replacement
    • 25. Rheumatoid Arthritis
      • - Chronic disabling systemic disease
      • - Often affects symmetrical peripheral joints
      • - Can affect all ages
      • - Auto-immune disease
      • - Diagnosed through symptoms, blood tests (ESR,RF,CRP) and X-rays
      • - Flares & relapses
    • 26. Rheumatoid Arthritis
      • Treatment aims:
        • Pain & inflammation relief
        • Preserve joint damage
        • Preserve / improve joint function
      • Treatment
        • DMARDs
        • NSAIDs
        • Simple analgesics
        • Systemic steroids
    • 27. Pharmaceutical care issues – Understanding and compliance are they taking it if not why not?
      • Fear of hidden long term risk
      • Fear of becoming immune to effects over time
      • Fear of addiction
      • Previous experience of ADR or sub-optimal therapy
      • Patient beliefs
      • Misunderstanding of benefits or how medication works
    • 28. Effectiveness and safety
      • - Use of Pain diaries and pain scores
      • - Optimising timing frequency and dose
      • - Identifying undiagnosed neuropathic element
      • - Activities and time when pain is worse
      • - History of ulcer or gastric bleed
      • - Reviewing continued need for NSAID
      • - Co-morbidity-CVD, hypertension
      • - Confirm co-prescribing or buying of medications that may increase risk
      • - Enquire if they are experiencing side-effects
    • 29. Self-help
      • Encourage exercise e.g. Walking and tai chi
      • Self-help e.g. Pain Association
      • Acupuncture, acupressure are helpful-TENS machines
    • 30. Pharmaceutical Care Model Schemes Chronic Pain Project n=41-medication
      • NSAID 26 (63%)
      • Cox 11 3 (7%)
      • Paracetamol 7 (17%) !!!!
      • Co-codamol 18 (44%)
      • Co-dydramol 5 (12%)
      • Strong opioid 14 (34%)
      • Neuropathic 9 (22%)
    • 31. Continued prescribed
      • 73% had pain for more than 5 years
      • 7(17%) used neuropathic pain descriptors but were not prescribed medication to manage this
      • 16 (44%) described their pain as severe and often or continuous
      • 14 (34%) were purchasing OTC painkillers
    • 32. Continued
      • 9 (22%) prescribed NSAID reported having an ulcer or gastric symptoms, only 5 out of the 9 were co-prescribed a gastro-protectant
      • 25 (61%) reported side-effects,mainly constipation and GI
      • 11 referrals were made and 7 referrals were taken forward-unclear if people at GI risk or experiencing neuropathic pain were referred .
    • 33. Continued-Care issues
      • 10 (24%) understanding of medication-fear of adverse effects or taking combining pain killers
      • 15 (37%) optimising dose, frequency or timing of analgesia-before activity etc
      • 2 (5%) reducing risk advising not to take OTC purchases or person taking excessive amounts
      • 8 (20%) advised use of pain diary and follow up
    • 34. Why get involved?
      • Out of the six PCMS Chronic condition projects this group
      • were most supportive of the pharmacists current role and
      • wanted more help-they highlighted;
      • * Friendly and give good advice- side effects
      • * Provide good information and explain dosage
      • * Better than some GPs
      • * Would like more monitoring and follow up along with GPs-as they see pharmacist more often
    • 35. Continued Professional Development>Implementing the Pharmaceutical Care Needs Assessment Chronic Pain
      • Who will you target?
        • - Compound analgesics
        • - People unsatisfied with their pain control
        • - People over 65 on NSAIDs, with or without gastro-protection
        • - Cardiovascular patient on COX-II/NSAID
        • - Anyone that comes in during a quiet moment
        • - 19 patients involved in focus groups completed the PCNA on their own within 10 minutes-this can be done while they are waiting for prescriptions
    • 36. Continued Professional Development
      • - Plan and record
      • - What did you learn tonight-what are the gaps?
      • - How will you meet the gaps?
      • - What is happening locally in relation to effective pain management?
      • - How and when will you find out?
      • - Ideal therapeutic area for pharmacist prescribing
    • 37.
      • Thank you

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